Wednesday, April 22, 2020

Atypical Symptoms of COVID-19


             A novel coronavirus emerged in China in 2019, named as SARS-CoV-2, become a pandemic. Scientists, Researchers and Health care professionals are still learning about it. It is an endeavor to compile the unusual/atypical symptoms, as far as possible, from different reputed sources. It will help the health care personnel to remain aware of the possibility of dealing with a COVID-19 patient, when patients present with symptoms, similar to some other disease.
Fever, Cough, Shortness of breath; these are what have become known as the classic, tell-tale COVID-19 symptoms. However, there can be additional non-specific, atypical symptoms or different, less common ones that should alert the health care profession, the possibility of the infection. Those include, Sore throat, Diarrhea, Myalgia (muscle aches, body aches), abdominal pain, loss of smell or taste, conjunctivitis, Tiredness or fatigue.
At present the definition of a COVID-19 Suspected Case:
Suspected Case Definitions
A. Symptoms +
Travel History
B. Symptoms +
Epidemiologic Link
C. Severe Symptoms
A patient with ALL of the following:
  • acute respiratory illness
  • no other etiology that fully explains the clinical presentation
  • a history of travel to or residence in a country, area or territory that has reported local transmission of COVID-19 disease during the 14 days prior to symptom onset
A patient with ALL of the following:
·       any acute respiratory illness
·       contact of a confirmed or probable case of COVID-19 disease during the 14 days prior to the onset of symptoms
A patient with ALL of the following:
·       severe acute respiratory infection
·       requires hospitalization
·       no other etiology that fully explains the clinical presentation

1.    Loss of smell and taste has been reported with such a frequency in COVID-19 that some medical professionals suggest to take it as a cardinal feature for diagnosis, if, associated with features of respiratory infection, even common cold or seasonal flu. According to Carol Yan, an otolaryngologist from the University of California San Diego in the US, “if, you have smell and taste loss, you are more than 10 times more likely to have COVID-19 infection than other causes of infection."
The loss of smell reported to be so profound that the patient starts nauseating just at the sight of food. He further says, while the most common first sign of a COVID-19 infection remains fever, fatigue/loss of smell and taste follow as other very common initial symptoms.
Based on the findings, UC San Diego Health has included loss of smell and taste as a screening requirement for visitors and staff, as well as a marker for testing patients who may be positive for the virus. The original article was published in The Week on April 14, 2020 15:14 IST, can be accessed here.
2.   Abdominal discomfort may be the presenting symptom in as many as 20 percent of patients. Recent literature has revealed that as many as 20 percent of patients present to the hospital with a digestive symptom, such as diarrhea, vomiting, pain, accompanying their respiratory symptoms. And, roughly 5 percent show up with an abdominal complaint alone.
This is where abdominal radiologists can play an integral role, said industry experts in a recent article published in the American Journal of Roentgenology. A team, led by Abraham Dachman, M.D., professor of radiology and abdominal imaging specialist with UChicago Medicine, shared three cases where patients were referred for abdominal imaging and providers distinguished findings indicative of COVID-19 infection in the lung base.
Axial CT of abdomen and pelvis shows left basilar round airspace and ground-glass opacities (arrow). Appearance is highly compatible with atypical infection such as coronavirus disease (COVID-19) pneumonia.
The article published on April 20, 2020, can be accessed here. 
3.   The gastrointestinal presentation can delay the initiation of COVID-19 diagnostic workup. Notably, however, the first case of COVID-19 infection confirmed in the United States reported a 2-day history of nausea and vomiting on admission followed by loose stools in hospital on day 2, and COVID-19 viral nucleic acids of loose stool and respiratory specimens were reported positive. In a recent report from Hubei, China, 204 COVID-19-infected patients were studied, and the authors reported that digestive symptoms are not uncommon in patients with COVID-19. The original article, published in The Karger, can be accessed here.

According to the WHO, digestive issues like diarrhea and nausea may be a more common symptom than previously thought.

4.   Conjuctivitis: Several reports suggest that SARS-CoV-2 can cause a mild follicular conjunctivitis otherwise indistinguishable from other viral causes, and possibly be transmitted by aerosol contact with conjunctiva. However, at this point in the COVID-19 pandemic, practically any patient seen by an ophthalmologist could be infected with SARS-CoV-2, regardless of presenting diagnosis, risk factors, indication for visit or geographic location. Updated on April 21, 2020, online by American Academy of Ophthalmology, can be accessed here.  Access the Ocular manifestations of a hospitalized patient with confirmed 2019 novel coronavirus disease in The British Journal of Ophthalmology here.
5.    Malaise and Confusion can be present in varied number of patients of COVID-19 are some of the atypical symptoms, according to an article published in The Lancet.
               In a study, the most common symptoms at onset of illness were fever (40 [98%] of 41 patients), cough (31 [76%]), and myalgia or fatigue (18 [44%]); less common symptoms were sputum production (11 [28%] of 39), headache (three [8%] of 38), haemoptysis (two [5%] of 39), and diarrhea (one [3%] of 38). More than half of patients (22 [55%] of 40) developed dyspnoea.
6.       Headaches and dizziness may also be signs of the viral infection: According to the study in The Lancet, about 8 percent of COVID-19 patients reported headaches. Dizziness has also been reported in some cases – frequent dizzy spells or very severe or abrupt bouts of dizziness could indicate a more serious health risk, according to the Cleveland Clinic.
7.       Chills or muscle aches occasionally accompany COVID-19. Aches and chills can be symptoms of many illnesses, including the flu, but coronavirus patients have reported them. It's not clear how prevalent these symptoms are, but about 11 percent of people studied reported chills, and 14 percent reported muscle aches, according to the WHO report.
8.       Runny nose is rarely a sign of coronavirus: It is more indicative of allergies or a cold. A minority of COVID-19 patients experience nasal congestion or a runny nose – less than 5 percent of people experience these symptoms, according to the WHO report.
9.       Acute myocarditis is thought to be a possible complication associated with COVID-19. While, it is required to closely monitor such patients for the complication, medical profession should keep in mind to test for the COVID-19, whenever other symptoms or epidemiologic link is available. Laboratory testing, including troponin levels, in individuals with recent symptoms of an acute illness should be performed to guarantee appropriate identification and prompt isolation of patients at risk of COVID-19 and eventually to reduce further transmission. The article published in JAMA Network on March 27, 2020, can be accessed here.
10.    Necrotizing encephalopathy: A woman who tested positive for COVID-19 developed a rare brain disease known as acute necrotizing encephalopathy, a condition that can be triggered by viral infections like influenza and herpes.
               At this point, the brain damage "has yet to be demonstrated as a result of COVID-19 infection," according to a case report published March 31 in the journal Radiology. However, as the novel coronavirus continues to spread, "clinicians and radiologists should be watching for this presentation among patients presenting with COVID-19 and altered mental status," the authors wrote.
               The original article published online by the Radiological Society of North America on here
11.                  Asymptomatic (subclinical): Now-a-days, a large number of asymptomatic (in pre-clinical/pre-symptomatic stage) patients are seen positive for COVID-19; many are also seen with mild symptoms (easily ignored). Many more asymptomatic contacts are also positive for COVID-19. It may go up to 80%. Another study suggests that the number can be between 5% and 80%.
                       In those mild cases, the predominant CT in Lungs can be diagnostic, with the findings of ground-glass opacification, consolidation, bilateral involvement, and peripheral and diffuse distribution. Notably, in Shi and colleagues' study, the asymptomatic (subclinical) group of patients showed early CT changes, supporting what was first observed in a familial cluster with COVID-19 pneumonia. Published on February 24th, 2020 in The Lancet can be accessed here.
12.    Atypical symptoms of COVID‑19 can be more common in immune-suppressed or immune-compromised patients. They may present with the symptoms of COVID‑19; neutropenic sepsis and pneumonitis may be difficult to differentiate at initial presentation. Medical profession has to keep in mind to screen and triage all those patients to assess, whether they are known, suspected to have COVID‑19, or have been in contact with someone with confirmed infection. In that case, COVID-19 rapid guidance from National Institute for Health & Care Excellence, updated on April 17, 2020, can be followed. 


Atypical symptoms in COVID-19: the many guises of a common culprit: COVID-19 exhibits a diverse range of clinical presentations. Whilst classical respiratory symptoms of a dry cough have been underscored, these may be preceded by atypical symptoms. More generally, it is important not to neglect other disease manifestations, since they may represent alternative modes of viral dissemination.
In critically ill patients, evidence of raised inflammatory markers suggests that cytokine storm syndrome occurs in COVID-19 and may underlie some atypical presentations. Notably, the elderly and those with multiple co-morbidities are severely affected by COVID-19, and atypical symptoms in these susceptible groups warrant further investigation.

More Readings at:

1.    Published on Mar 31st, 2020, 23:28 IST in The Business Insider, India; 10 coronavirus symptoms you may not be aware of, from malaise and dizziness to digestive issues.

2.    Published on 1st April, 2020 in The ScienceAlert; Some COVID-19 Symptoms Are Turning Out to Be Atypical. Here's What We Know So Far

3.    Published on 05 April 2020 in thebmj in a letter to the Editor, under caption, “Atypical symptoms in COVID-19: the many guises of a common culprit.”

4.    Published on April 17th, 2020 in Medscape:   Unusual Presentations of COVID-19: 'Our Ignorance Is Profound'


 

 

(A Paradip Port Trust Hospital Document)



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